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The document is an 'Authorization for Release of Information' form from the Commonwealth of Pennsylvania's Department of Public Welfare. It allows individuals to authorize the disclosure of personal information related to their eligibility for public assistance, including details about age, residence, employment, and income. The information will be used solely for assessing eligibility for public assistance benefits.

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What is a PA-4 form for Medicaid?

The PA-4 form will be used to assist the assessor in determining whether home and community based long-term care services can best meet the needs of the individual. Complete the top portion of the PA-4 with the individuals name, address, phone number, date of birth, veteran status, Social Security and Medicaid number.

What is a prior authorization form for medical assistance in PA?

A Pennsylvania Medicaid prior authorization form is a document used to obtain Medicaid coverage for non-preferred drugs in the state of Pennsylvania. A physician must submit this form when they wish to treat a Medicaid patient with a medication that is not on the states preferred drug list.

What is a PA 162 form used for?

PA Form 162 is a tax form used for Reporting Business Gross Receipts Tax. It is required to be filed by individuals or businesses operating in Philadelphia, Pennsylvania, who are subject to the Business Income and Receipts Tax (BIRT).

Is it PA or PA for Pennsylvania?

The states four most populous cities are Philadelphia, Allentown, Pittsburgh and Erie. Along Lake Erie Pennsylvania has 82 km or 51 miles of coastline, while along Delaware Esttuary it has 92 km or 57 miles of shoreline.

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